DRUGS USED IN ANGINA

PECTORIS & MYOCARDIAL

INFARCTION

TRULYSITORUS
TRULY SITORUS
Depart.of.Pharmacology&&Therapy
Depart.of.Pharmacology Therapy
FacultyOf
Faculty OfMedicine
MedicinePadjadjaran
PadjadjaranUniversity
University
 ANGINA PECTORIS
A syndrome of inadequate oxygen delivery to
the myocardium relative to the oxygen
requirement of this tissue
Symptom
Severe, transient retrosternal pain
radiated to the left arm, back or jaw
Duration:
0,5 30 minute
ECG:
 ANGINA PECTORIS
O2 Supply

Ischemic

PAIN
TYPE OF ANGINA PECTORIS
1. CLASSIC ANGINA
Atherosklerosis
Precipitating factor (+)
2. PRINZMETALS
Vasospasm
Precipitating factor (-)
3. UNSTABLE
A rapid increase in frequency and intensity of
anginal pain occurs, which is thought to herald
imminent myocardial infection.
Angina Pectoris PATHOPHYSIOLOGY (I)
RISK FACTOR
Age Hypertension
Smoking Hypercholesterolemia
DM Oral contraception
Genetic ?

atherosklerosi
s

OBSTRUCTION (a.coronary)

Decreased 02 supply
Angina Pectoris

PATHOPHYSIOLOGY II

O2 supply & O2 demand

Precipitating factors

ISCHEMIA

PAIN
 PRINCIPLES IN THE TREATMENT OF
ANGINA PECTORIS

1. O2 supply to the tissue

2. O2 demand of the tissue

3. Risk Factor
 ANTI ANGINAL DRUGS
1. ORGANIC NITRATES
AMIL NITRIT
NITROGLYCERIN
ISOSORBIDE DINITRATE
2. Ca ++ CHANNEL BLOCKERS (CCB)
NIFEDIPINE, AMILODIPINE
DILTIAZEM
VERAPAMIL
3. ADRENERGIC BLOCKERS
PROPANOLOL cs
 NITROGLYCERINE
Nitroglycerine the prototype nitrate drug.
All nitrates have the same mechanism of Action.
MECHANISM OF ACTION
Administrated nitrates

Nitrites

Nitric oxide (NO)

cGMP

Dephosphorylation of myosin light chain

Vascular smooth muscle relaxation

Nitroglycerin
EFFECT

Venodilatation

Relief of
Preload coronary a spasm Collateral flow

O2 demand O2 supply O2 supply

Inotropic ?
Chronotropic ?
Nitroglycerin

EFFECT
High Dose
Vasodilatation

BP

tachycardia

Paradoxal effect O2 demand

Nitroglycerin

EFFECT

1. Increased O2 supply
2. Decreased O2 demand
Preload
Afterload
3. Contractility (N)
4. Heart rate
5. Decreased in platelet aggregation (?)
Dosage
Nitroglycerin

INDICATION

ANGINA PECTORIS
Acute
Prophylaxis
ACUTE MYOCARDIAL INFARCTION
CONGESTIVE HEART FAILURE
Nitroglycerin

ADVERSE DRUG REACTIONS

Common side effects
Headaches
Serious SE
Hypotension Syncope ( cause cerebral ischemia)
tachycardia
Others
Edema
Methemoglobinemia
SL: Burning sensation
Withdrawal symptoms
Tolerance
Nitroglycerin
ADVERSE DRUG REACTIONS

Tolerance
Appears within 12 hours
Long acting preparation
Continuous infusion
Caused: - BM depletion
Avoid by a nitrate free interval
Cross tolerance
Nitroglycerin

CONTRAINDICATION

Hypotension
Severe anemia
Brain injury
Tachyaritmia
 CALCIUM CHANNEL BLOCKERS
(CALCIUM ANTAGONIST)

I. NIFEDIPINE
AMLODIPINE, FELODIPINE,
NICARDIPINE, NIMODIPINE, ETC
II. DILTIAZEM
III. VERAPAMIL
CCB
MECHANISM OF ACTION
Inhibit the influx of Calcium into CARDIAC
& VASCULAR cells MUSCLE TONE
 CCB
EFFECTS (I)

Vascular Effects Cardiac Effects

Vasodilatation Heart Rate Conduction

O2 supply After load BP Contraction

O2 demand O2 demand
CCB
EFFECTS (II)
Phenylalkylamines Dihydropyridines Benzothiazepines
A (Verapamil) D (Diltiazem)
B(Nifedipine) C(Nimodipine)
Vasodilatation
Peripheral ++ +++ + +
Coronary ++ +++ + +++
Cerebral + + +++ +
Heart Rate -

SA Node -
-
AV Node -
-
Contractility -

 Pharmacokinetics

Drug Absorption Bioavailability Active Half Onset Peak

Metabolites Life of Effect
(hr) Action after
after oral
Oral Dosing
Dosing

Verapamil >90% 10%-35% + 5 <1hr 1-2hr

Nifedipine >90% 60%-70% - 2 <20min 30min
(2-3
min)*
<1hr
Diltiazem >80% 40% + 3,5 2-3hr
 CLINICAL PROBLEMS AND SIDE EFFECTS
VERAPAMIL
Problems in 8% to 10% of patients
Major
Moderate Cardiodepression
Hypotension
AV node block
Minor Peripheral edema
Headache
NIFEDIPINE
Constipation
Problems in 17% to 20% of patients
Major

Hypotension
DILTIAZEM Headache
Problems in 2% to 5% of patients Peripheral edema
Minor

Hypotension -AV Node Block

Peripheral edema -Cardiodepression
 NIFEDIPINE

Effects (?)
SE: VD flushing, dizziness, headache,
palpitation, peripheral edema
rare myalgia, hypokalemia,
gingival swelling
Drug Interaction
Cimetidine
Prazosin
Nifedipine

Indication
1. PRINZMETAL,S (VASOSPASTIC) ANGINA
Monotherapy, 40-80 mg
More effective when combined with Isosorbid
2. CHRONIC STABLE ANGINA
Combined with Beta Blocker
3. UNSTABLE ANGINA
Monotherapy is contraindication
Combined with Beta Blocker
Nifedipine
SECOND GENERATION DHP

AMLODIPIN: OOA
DOA
DI
SE
Dosage: 5-10 mg, once daily
NICARDIPINE: Dosage: 20-40 mg, every 8 hours
NIMODIPINE : Subarachnoid Hemorrhage
Migraine
 DILTIAZEM

EFFECTS:
SE:
INDICATION:
CONTRAINDICATION:
 VERAPAMIL

EFFECTS:
SE:
INDICATION:
CONTRAINDICATION:
 BETA BLOCKER
CARDIOSELECTIVE
Acebutolol
Atenolol *
Metoprolol *
NON CARDIOSELECTIVE
Propanolol *
Nadolol *
Carteolol
Sotalol
VASODILATOR NONSELECTIVE
Labetolol
Pindolol
Carvedilol
 PROPANOLOL
Is the prototype adrenergic blocker
Inotropic
chronotropic O2 demand
Adrenergic domotropic
blocker
Renin Ag peripheral BP
resistance

aldosteron

Sodium, water BP
retention
INDICATION

I. ANGINA PECTORIS
For Chronic management of stable angina
II. MYOCARDIAL INFARCTION
Reduces infarct size and has tens recovery
Reduce the incidence f sudden arrhythmic death
after myocardial infarct
III. HYPERTENSION
IV. ARRYTHMIA
V. MIGRAINE
VI. GLAUCOMA
VII. HYPERTHYROIDISM
 Propanolol
SIDE EFFECTS
SELECTION OF DRUGS

Drugs ESR Liposoluble FPE Elimination T 1/2

Propanolol +++ ++ L 1-6

Nadolol 0 0 0 K 20-24

Atenolol + 0 0 K 6-7

Metoprolol + + ++ L 3-7
CONTRAINDICATION

Severe bradycardia, heart block

Asthma or bronchospasm
Severe depression
Peripheral vascular (gangrene, skin,
necrosis, Raynauds phenomenon)
DM
Renal failure
ACUTE MYOCARD INFARCT

O2 Supply

Infarct

PAIN
 THERAPY
1. Oksigen
2. Morfin
3. Metaklopramide
4. Nitrogliserin
5. Aspirin
6. Streptokinase
7. Heparin
8. Laksativ (bila perlu)
Other Drugs

ACE INHIBITOR
Reduce:
1. Remodeling ventricle
2. Haemodinamic
3. Reduce heart failure

BETA BLOCKER
1. Reduce O2 myocard demand
2. Reduce size of infarct
Kasus:
Seorang laki-laki 56 tahun, datang dengan
keluhan sering nyeri dada (khas)
PD: TD= 200/100 mmHg
Diagnosis: Angina Pectoris Klasik
Pertanyaan:
- Bagaimana terapi akut, kronis, lainnya
Seorang wanita 62 tahun, datang dengan
keluhan nyeri dada terutama pagi hari.
PD: TD=180/90, Riwayat DM (+)
Diagnosis: Angina Pectoris Vasospastik
Pertanyaan:
- Bagaimana terapi akut, kronis, lainnya ?
Seorang laki-laki, 60 tahun datang ke UGD
dengan keluhan nyeri dada hebat, muntah,
keringat dingin
PD: TD= 180/100
Diagnosis: Acute Myocard Infarct
Pertanyaan:
- Bagaimana penanganan pasien tersebut?